Implementing Health Care Advances in Practice Settings. Recent technological advances have engulfed the health care field, but have not generally resulted in improved health care for many common conditions. The sophistication of diagnostic tools has increased ten-fold in the last two decades, including such exotic technologies as nuclear magnetic resonance imaging to detect the spin state of individual protons within a patient's body for characterizing select structures and disturbances within key organs. Other advances include genetically engineered antigen labels for accurately identifying destructive organisms, and precisely configured synthetic analogues of metabolic agents with high specificity for triggering select defensive responses.
These technologies will continue to grow exponentially as health care becomes increasingly important to a relatively wealthy, but rapidly aging society. Indeed, a significant barrier to advances in health care is their cost, which grows faster than the general inflation rate. Additionally, knowledge of how to apply available advances in real practice settings is limited. Despite dramatic technological advances in many areas, management of several common functional disorders (such as dyspepsia, irritable bowel syndrome, chronic fatigue syndrome, and fibromyalgia) has not substantially improved. Patient dissatisfaction with conventional medical management of these common disorders has fueled huge expenditures of personal health dollars for alternative care, much of which remains of uncertain benefit and risk.
Inadequate physician time for optimal patient care. Health care costs have risen steeply and, with physician time a valuable commodity, few clinicians can spend more than a fraction of an hour-even with new patients. In the past, a patient's expectations were largely inspired by the image of a house-calling physician who devoted hours of personal “bedside” attention to every patient, a model seldom found today. In many environments physician time is so limited as to preclude a comprehensive evaluation. Inattention to detail or inadequate assessment of the patient's overall biopsychosocial situation can generate inefficiencies of care.
The challenge of patient assessment: nonspecific and overlapping symptom patterns. More than 30% of the population experience functional disorders that cause symptoms without any corresponding organic pathology. The clinical challenge is to appropriately recognize these functional disorders and discriminate them from less common cases of organic disease that require specific therapy. One barrier to efficient clinical evaluation is that the symptom patterns of organic disease and functional disorders are surprisingly nonspecific; for most visceral disorders, there is only a weak correlation between a given symptom complex and underlying organic disease. For example, only 10 to 20% of patients with classic “peptic ulcer” symptoms have ulcers and many patients with ulcers are asymptomatic or present with other than classic symptoms. Another barrier is that patients presenting with acute or chronic functional disorders or organic disease may have multiple symptom complexes that overlap. Overlapping symptoms are the rule; they confound the diagnostic process and obscure organic disease that requires specific diagnosis and/or therapy.
Patients must be primed to understand the features of their symptoms and essential medical terms so that they can provide a diagnostically-relevant history. The rapid-fire questions of a rushed physician interview do not allow time for most patients to understand the issues and think through their answers. When patients are rushed or feel as if they are not listened to, anxiety mounts and the outcomes of care deteriorate.
Extracting a history from patients, especially in the face of overlapping problems, requires diligence, skill, and time. However, conventional logic assumes that the non-specificity and overlap of symptoms obviates benefit from a detailed history. In addition, the process of unraveling an adequate history takes time and the expectation that the process will yield valuable clinical information. Furthermore, the onslaught of technology has displaced history taking and symptom pattern recognition, rendering these skills underutilized and unrefined for most physicians. For these reasons, an adequate history is rarely obtained. When physicians are not clear on symptom presentation and basic pattern recognition, they are driven to perform more tests, use more medications, or refer patients for consultations, procedures, or even surgery. Accordingly, costs escalate and the efficiencies of care are lost.
Physician information overload. Sophisticated new technologies provide a volume and complexity of diagnostic information that can easily overwhelm practicing clinicians. Few physicians can effectively manage and utilize advanced equipment, space age therapeutic regimens, and the massive amount of information that goes with them. Ironically, health care providers are even overwhelmed with the process of handling medical records for patients. Paper charts are outmoded, especially in poly-physician environments where there is rarely the time to carefully read complex and often poorly organized charts. Sophisticated electronic medical record (EMR) systems have been developed to handle laboratory records and other patient information. However, available EMR systems do not (1) collect and process information from patients, (2) transmit patient data to physicians, or (3) manage historical data regarding the physician-patient interaction (patient history, physician assessment, follow-up data) in a dynamic, efficient manner. The inadequacies of current patient data management systems disrupt the process of care.
Patient information overload and lack of self-care. Like clinicians, patients encounter information overload. Typically, a patient is provided with information regarding their problems and possible treatments in technical jargon that leaves them bewildered and intimidated. The information that should clarify the nature of their problem becomes an almost insurmountable barrier to understanding. In addition to being incomprehensible, health instructions and treatment plans may also be impractical for an individual patient's lifestyle, and thus will not encourage compliance. Thus, the patient becomes alienated from their potential role in the care process, leading to a poor response to treatment.
Failure to capitalize on patient-centered care. Although patient outcomes and the efficiency of care will be improved by an integrated approach to the whole patient and the physician-patient interaction, conventional medicine perseveres in its biomedical focus on disease, tests and medications. Notwithstanding rapid technological advances in medicine, the patient's initial psychological status and response to the therapeutic process plays a substantial role in the overall success of treatment. The highly variable, but well-documented “placebo response” reflects the inherent role of patient health attitudes and the quality of the physician-patient interaction on the patient's response to therapy. The potential benefits of patient-centered elements of the care process (Table 1) are evident, but they are difficult to implement in most busy, resource-limited practice settings. (Reference: Stewart, M., J. B. Brown, W. W. Weston, I. R. McWhinney, C. L. McWilliam, T. R. Freeman, and K. A-Kaila. 1995. Patient-centered medicine: transforming the clinical method. Sage Publications, Thousand Oaks, Calif. 117 pp.)
Controlling costs while preserving quality of care. As health care costs have skyrocketed, many cost-saving solutions have been explored in the health care marketplace. Per capita costs have been cut to preserve profits, jeopardizing health outcomes and the quality of care. The challenge is to ensure that the quality of and access to care are maintained and improved, while costs are contained. Health care managers must make difficult decisions when attempting to control costs while preserving the quality of care. There is great potential for waste through misapplication of care on one hand, or under-utilization of indicated treatments on the other.
The process and outcome data needed for cost-saving, quality-preserving decisions. Disease management guidelines have been developed in an attempt to standardize care and control costs. However, methods are not available to appropriately test, implement, and monitor specific disease management guidelines that have been developed in an effort to control costs while maintaining the quality of care. Decisions regarding allocation of health care resources generally rely on available data for treatment efficacy in study populations. However, these efficacy data often fail to predict the treatment effectiveness in real practice settings. The information needed to make decisions regarding health care utilization are data from real practice settings on patient outcomes (how the patient felt and functioned before and after treatment), the process of care (what the physician did and thought), and the costs. Health care providers do not have the time to verbally gather or record process and outcome data. Paper questionnaires are also an impractical and inefficient means to gather high quality data. Therefore, the health care delivery system currently lacks the tools to measure the impact of treatment on the outcomes and quality of care. Practical systems are needed to routinely perform these essential measurement tasks.
The predicate for the present invention is informed by the problems inherent in the current health care delivery infrastructure cited above. It is with recognition of these problems in the state of the art that the present invention provides the following objects.